AFFIDAVIT

I, (Insert Name of Affiant) , Filipino citizen, of legal age, single/married to (Insert Name
of Spouse if any), and a resident of (Insert Address of Affiant), after having been duly sworn in
accordance with law, hereby depose and say:

1. That................................................................................................................
...........................................................................................................................
...........................................................................................................................

2. ........................................................................................................................
............................................................................................................................
............................................................................................................................

3. ........................................................................................................................
............................................................................................................................
............................................................................................................................

Further Affiant sayeth none.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ......... day of

..................... , 20__ in ..................................... Philippines.

........................................................................
(Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN before me this........ day of ........................... 20__, by

............................................. who exhibited to me his CTC No. ................................... issued
on ................................. at ...........................................

Notary Public

Doc. No. .........:

Page No. .........;
Book No. .........;
Series of 20__.